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Debriefing: Facilitating Discussion to Build Highly Reliable Teams and Improve Systems
Julie Arafeh MSN, RN
Disclosures
I have no relevant disclosures
I do not have any commercial support
I do not endorse any specific product, service or system
Learning
Objectives
Review goals of debriefing, setting up a structure for successReview
List debriefing questions that facilitate team building and uncover system issues
List
Apply debriefing questions to video clips of simulation training sessionsApply
Debriefing: The Basics
Definition
Facilitated discussion of the
events of a patient care
situation to gain a better
understanding of the
events that occurred in
order to improve care and
team performance
Can occur after training or
actual patient event
Sources for Debriefing
LEARNING OBJECTIVES/METRICS
INTERESTING OR UN-ANTICIPATED EVENT DURING SCENARIO
QUESTION OR CONCERN FROM ATTENDEES DURING
DEBRIEFING
HYPOTHETICAL SITUATION
Debriefing to Build Teams
Key part of simulation-based training considered to be an integral part of achieving the
goals of improved patient care and team building
Knowledge of environment
Anticipate and plan
Role delegation
Communication
Leadership
Situation awareness
Call for help
Maintain professional behavior
Team Skills Best Debriefed with Video
Objective
Allows attendees to view team skills
Facilitates discussion about team skills
Video
EQUIPMENT EASY TO USE
MUST HAVE A CLEAR PLAN FOR HOW VIDEO WILL
BE USED
MUST HAVE A CLEAR PLAN FOR HOW VIDEO WILL
BE DESTROYED
SHARE PLAN FOR VIDEO WITH ATTENDEES
Debriefing Prerequisites
Consult with attorney and/or Risk Management to ensure all debriefings and findings are non-discoverable
1
Form for real event debriefing
2
Lead debriefersattend training for debriefing
3
Have a structure in place for evaluation of debriefers
4
Role of the
Debriefer
Observation or recording of team actions to analyze how they impacted patient care
Comparison of performance to a checklist or cognitive aid
Metrics of key actions
Setting Up for Success
Investigate topic for concerns
Measurable learning
objectives
Determine metric
Units of measure that
reflect performance
Use a checklist
Metrics
Metrics are measurements of process or system performance
Time help requested until time of arrival
Time medication requested until time medication is administered
Goal of metrics
Validate that a process or system needs improvement
Collect data to support change, evaluate change, confirm improvement in system
Aid in identification of best practice
Checklists for Aviation
Checklists for Healthcare…..
Case Example: Post-Partum
Hemorrhage
Pre-Work: Investigate the Topic
Why was this topic chosen for simulation
training?
What are the main issues with
this topic?
QI
Interview nurses, physicians,
CNM, techs, clerks
Sentinel events or near misses?
Measurable Learning Objectives
Shorter scenarios are easier to debrief, consider a max of 3-5 learning objectives
Narrow the focus of the training
What is the most urgent issue for staff training
What processes can be put into place to address the other issues that aren’t covered in the training
Measurable Learning Objectives
Know uterotonic medications
Verbalize uterotonic medications in hemorrhage protocol and contraindications for use
Review massive transfusion protocol
Verbalize key actions in massive transfusion protocol and role delegation for tasks to accomplish
protocol
Assist with uterine tamponade device
Set up and assist with uterine tamponade device insertion following process in protocol
Measurable Learning Objectives
Utilize good communication skills
Team utilizes directed, closed loop communication for medication orders/administration, role
delegation and all communication with the leader
Assume the leadership role
Demonstrate leadership through announcing role, continued reassessment of patient/situation,
and invitation of input from team
Avoid fixation errors
Activate timer when setting up rapid infuser, when timer sounds inform leader on status of use of
the equipment
Call for help early
Call OB rapid response when bleeding measured at XXXml/presence of early warning criteria
Metrics: Based on Learning Objectives
Time uterotonic medication ordered to time correctly administered to patient
Time uterine tamponade device ordered to time insertion begins
Time uterine tamponade device insertion begins to time procedure successfully
completed
Time massive transfusion ordered to time blood enters patient room
Time blood enters room to time patient begins to receive blood
Checklist
Develop a checklist based on evidence-based protocol
Test protocol in simulation
Key actions placed into a checklist
Checklist tested in simulation for usability and readability
Assign team member to be responsible for checklist
PPH Checklist PP H Checklist
Recognize Call for Help TreatTransfuse
early
STEP 2: IDENTIFY & TREAT CAUSE ~ Atony, Laceration, Retained Placenta, Coagulopathy
□ Vitals q1-2 min □ PPH kit + PPH cart □ 100% oxygen □ Fundal massage
□ IV fluids - high rate □ Urinary catheter
□ 2 wide-bore IVs □ Uterotonics
Pitocin 1-2 unit boluses (anesthesiologist only)
Max 40 u/500 mL (max rate 500 mL/hr)
Methergine 0.2 mg IM q2-4 hr __________
Hemabate 0.25 mg IM q15 min __________
Repeat dose @ __________
Misoprostol 600-800 mcg SL __________
STEP 3: ASSESS MAGNITUDE Phase 1 (first 5 - 10 mins)
□ Consider doing a RECAP now: VS, amt blood loss, cause of bleeding if known, actions completed in Step 2
□ Send STAT labs (ABG, CBC, PT/PTT, INR, Fibrinogen, iCa, TEG)
□ Activate Massive transfusion protocol □ Resuscitate using rapid infuser
□ Assess QBL □ Intrauterine balloon placement
Phase 2 (10 - 15 mins)
□ Early transfer to OR (if bleeding is ongoing) or IR (if bleeding ongoing + stable)
□ Consider cryoprecipitate (or fibrinogen concentrate, RiaSTAP) and
□ Consider tranexamic acid 1g IV
□ Treat hypocalcemia □ Maintain normothermia
STEP 1: CALL FOR HELP!
□ Primary Provider □ Emergency response team for OB
□ Assign nursing roles. □ Other :
Time given:
Debriefing Questions: Get to WHY
What uterotonic medications are appropriate for this patient?
Determines knowledge base, explanation of why specific medication chosen illustrates decision making process for less experienced staff
What are the key actions that need to be accomplished in the massive transfusion protocol (insertion of uterine tamponade device)?
What actions were accomplished for this patient?
What circumstances allowed the team to complete key actions?
How can this be replicated in actual patient care?
What circumstances prevented the team from completing the key actions?
What changes can the team make to complete key actions?
How can this be replicated in actual patient care?
Debriefing Questions: Get to WHY
Communication
What information does the team need to communicate when medication is ordered (roles are
assigned)?
What information was communicated by the team?
What circumstances allowed the team to communicate necessary information?
How can this be replicated in actual patient care?
What circumstances prevented the team from communicating necessary information?
What can the team do to ensure complete communication? How can the team consistently make sure closed loop
(directed) communication is used?
How can this be replicated in actual patient care?
Debriefing Questions: Get to WHY
Leadership
Red Flags
Several traditional ‘leaders’ may be involved in the scenario – how will team decide who the leader is OR how will patient management be coordinated if more than one leader
Consider adding a nurse leader role; physician/NP manages the patient but the nurse manages and organizes the room
GOAL: Anticipate and plan to reduce time between order and execution of the order, reduce errors of omission and
commission
Debriefing Questions: Get to WHY
Leadership
Did the team have a leader(s)?
How was the role of leader established?
How many tasks did the leader have?
What impact did that have on patient care?
How can the team assist the leader with multiple tasks?
If no leader, how did the absence of a clear leader impact patient care?
What actions can the team take if no clear leader has been established?
Debriefing Questions: Get to WHY
Avoid fixation error
What effect did the timer have on using the rapid infuser?
What impact did the timer have on patient care?
Debriefing Questions: Get to WHY
Call for help
What prompted the call for help?
What tasks/activities/roles need to be done by those coming to help?
What tasks/activities/roles were completed by those coming to help?
What circumstances led to those coming to help taking on (or not taking on) tasks/activities/roles?
How can the team make sure those coming to help are given appropriate tasks/activities/roles?
How can this be replicated in actual patient care?
Data from Debriefing
Keep a list of:
System issues
Suggested solutions
Examples of best practice
Data from
Debriefing
and
Simulation
TrainingHave a structure in place to address
findings
Compile a report of
MetricsData from debriefing
Report back
to Attendees
Let attendees know what
changes have been made
due to findings from
simulation training and
debriefing
Case Example: Maternal Cardiac
Arrest
Pre-Work: Investigate the Topic
Why was this topic chosen for
simulation training?
What are the main issues with
this topic?
QI
Interview nurses, physicians, CNM,
techs, clerks, code team
Cases of cardiac arrest and outcome
Measurable Learning Objectives
Shorter scenarios are easier to debrief, consider a max of 3-5 learning objectives
Narrow the focus of the training
What is the most urgent issue for staff training
What processes can be put into place to address the other issues that aren’t covered in the training
Measurable Learning Objectives
Verbalize additional actions that need to be taken during maternal cardiac arrest
Demonstrate correct placement of defibrillator pads, generation of a cardiac rhythm and defibrillation (if needed) using manual or AED mode on defibrillator
State optimal location of emergency equipment in room to facilitate maternal and neonatal resuscitation
Verbally clarify roles of leader, compressor, ventilator, crash cart/emergency med nurse, documenter/reader
Assemble supplies for resuscitative perimortem within three minutes after pulselessness established
Designate location for family in room or immediate area and notify support staff to be with family
Metrics: Based on national standards
Time pulselessness established to time chest compressions started
Time pulselessness established to time cardiac rhythm assessed and defibrillation (if
needed)
Time pulselessness established to time of resuscitative perimortem
Percentage of effective chest compressions
Peds/neonatal team present before birth
Area for neonatal resuscitation designated and prepared for resuscitation before birth
Checklist
Debriefing Questions: Get to WHY
Verbalize additional actions that need to be taken during maternal cardiac arrest
Were those actions accomplished for this patient?
What circumstances allowed (or prevented) the team from completing the actions?
What changes can the team make to accomplish all the actions?
How can this be replicated in actual patient care?
Cardiac rhythm was evaluated and treated XX minutes after pulselessness established
What circumstances allowed(or prevented) the team to (from) evaluating and treating the
rhythm within 3 minutes of established pulselessness?
What can the team do differently to meet the three minute standard?
How can this be replicated in actual patient care?
Debriefing Questions: Get to WHY
Did the maternal and neonatal teams have sufficient room for resuscitation?
If no, could the room be organized differently?
What barriers did the team face when providing resuscitation to mother/baby?
How can this be replicated in actual patient care?
What first responder roles are needed in maternal cardiac arrest?
What roles were assigned or assumed in this case?
What circumstances allowed (or prevented) all roles to be (being) filled?
What changes can the team make to fill all roles?
How can this be replicated in actual patient care?
Debriefing Questions: Get to WHY
Were the correct supplies available for resuscitative perimortem by four minutes of
established pulselessness?
What circumstances allowed (prevented) supplies being available to OB/ED MD?
What can team do to ensure supplies for resuscitative perimortem are available within 4 minutes of established pulselessness?
How can this be replicated in actual patient care?
What happened to the family during resuscitation?
What circumstances allowed (prevented) the team to address (from addressing) the needs of the
family?
How can this be replicated in actual patient care?
Data from Debriefing and Simulation
Compile a report of findings and send to appropriate
committees/departments
Report changes made due to simulation to staff
Case Example: Debriefing Real
Clinical Events
Debriefing Real Clinical Events
Concise – no more than ten minutes
Confidential Clear strategy to identify issues
Debriefing Real Clinical Events
Designate events for debriefing
1
Designate a person to debrief, timer
2
Develop a form for consistency
3
Components
of Form
Date and time
Staff that attended
Brief synopsis of clinical event
Issues:
Getting necessary staff, enough
people, correct skills set
Issues with medication, blood, fluids
Issues with equipment
Opportunities for improvement?
Challenges? Barriers?
Need to schedule a more in depth review, psychological debriefing?
References and Suggested Reading
Kearney, J. A., Deutsch, E. S. (2017). Using Simulation to Improve Systems. Otolaryngology Clinics of North America, 50, 1015-1028. http://dx.doi.org/10.1016/j.otc.2017.05.011
Gardner, A.K., Scott, D. J., AbdelFattah, K. R. (2017). Do great teams think alike? An
examination of team mental models and their impact on team performance. Surgery, 161, 1203-8. http://dx.doi.org/10.1016/j.surg.2016.11.010
Fiscella, K., Mauksch, L., Bodenheimer, T., Salas, E. (2017). Improving Care Teams’
Functioning: Recommendations from Team Science. The Joint Commission Journal on Quality and Patient Safety, 43, 361-368. http://dx.doi.org/10.1016/j.jcjq.2017.03.009
References and Suggested Reading
Lacerenza, C. N., Marlow, S. L., Tannenbaum, S. I., Salas, E. Team Development
Interventions: Evidence-Based Approaches for Improving Teamwork. American Psychologist, 73(4), 517-531. http://dx.doi.org/10.1037/amp0000295
Merriel, A., van der Nelson, H., Merriel, S., Bennett, J., Donald, F., Draycott, T., Siassakos, D.
(2016). Identifying Deteriorating Patients Through Multidisciplinary Team Training. American Journal of Medical Quality, 31(6), 589-595. DOI: 10.1177/1062860615598573
Dahlberg, J., Nelson, M., Dahlberg, M. A., Blomberg, M. (2018). Ten years of simulation-
based shoulder dystocia training- impact on obstetric outcome, clinical management,
staff confidence, and the pedagogical practice- a time series study. BMC Pregnancy and Childbirth, 18, 361-369. https://doi.org/10.1186/s12884-018-2001-0
References and Suggested Reading
Yamada NK, Kamlin COF, Halamek LP. Optimal human and system performance during
neonatal resuscitation. Semin Fetal Neonatal Med. 2018 Oct;23(5):306-311. doi:
10.1016/j.siny.2018.03.006. Epub 2018 Mar 7.
Daniels K, Hamilton C, Crowe S, Lipman SS, Halamek LP, Lee HC. Opportunities to Foster
Efficient Communication in Labor and Delivery Using Simulation. AJP Rep. 2017
Jan;7(1):e44-e48. doi: 10.1055/s-0037-1599123.
Halamek LP. Simulation and debriefing in neonatology 2016: Mission incomplete. Semin
Perinatol. 2016 Nov;40(7):489-493. doi: 10.1053/j.semperi.2016.08.010. Epub 2016 Oct 31.
Sawyer T, Loren D, Halamek LP. Post-event debriefingsduring neonatal care: what are we
not doing them and how can we start? J Perinatol. 2016 Jun;36(6):415-9. doi:
10.1038/jp.2016.42. Epub 2016 Mar 31.